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Patient Care Coordinator RN

4 weeks ago

Vienna, West Virginia, United States Kaiser Full time
Job Summary:

The Patient Care Coordinator RN is responsible for overseeing the management and coordination of care for the acute inpatient population. The RN collaborates with physicians, patients, families, nursing staff, and other healthcare team members to ensure a continuum of patient care progression for clinical and cost-effective outcomes. The RN facilitates and coordinates with community providers and ambulatory case managers to assist with the appropriate level and transition of care for a safe discharge and preventing re-admission.

Key Responsibilities:
  • Conduct initial face-to-face assessments for admitted patients to identify discharge needs within 24 hours of admission.
  • Document assessment outcomes in the electronic medical record and communicate with the healthcare team to determine the appropriate transition plan.
  • Participate in daily Care Without Delay (CWD) rounds to report on patient progression towards the established discharge plan.
  • Review and document discharge plans in accordance with KP discharge planning documentation policies, facility policies, and regulatory requirements.
  • Manage timeliness of care progression with physician and nursing staff to prevent avoidable delays and days.
  • Collaborate with Social Workers to coordinate long-term care, assisted living, financial assistance, and other services as required.
  • Send referrals and communicate with in-network vendors for coordination of post-acute levels of care such as Home Health, DME, IV infusion, SNF, Sub-Acute, and Acute Rehab.
  • Timely identification, recording, and escalation of delays in care and barriers to discharge. Provide solutions to correct delays and recognize systemic patterns that require corrective action.
  • Assure follow-up appointments and referrals to ambulatory case managers for high-risk patient populations are scheduled and communicated to patients and families prior to discharge.
  • Observe all facility safety policies and procedures, including infection control, Member Rights policies, and regulatory requirements.
  • Participate in Quality Assurance duties and implementation of programs to improve care Quality Indicators.
  • Maintain professionalism with all duties in an effective and timely manner as directed or assigned by designated supervisors.
  • Consistently work cooperatively with patients, patient representatives, facility staff, physicians, consultants, and ancillary service providers.
Requirements:
  • Minimum of one year of experience in an acute medical/surgical/ED or critical care nursing area.
  • Associate Nursing degree required.
  • Registered Nurse License (Maryland) within 6 months of hire and Registered Nurse License (Virginia) within 6 months of hire, or Compact License: Registered Nurse within 6 months of hire, and Registered Nurse License (District of Columbia) within 6 months of hire.
  • Basic Life Support.
Preferred Qualifications:
  • Recent acute care, case management, or home health experience preferred.
  • BSN preferred.

Kaiser Permanente is an equal opportunity employer committed to a diverse and inclusive workforce. Applicants will receive consideration for employment without regard to race, color, religion, sex (including pregnancy), age, sexual orientation, national origin, marital status, parental status, ancestry, disability, gender identity, veteran status, genetic information, other distinguishing characteristics of diversity and inclusion, or any other protected status.